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Noninvasive breast cancers constitute 10% of all types of breast cancer. The diagnosis has increased with early detection through mammography. The prognosis is good. Treatment is aimed at preventing the development of an invasive breast cancer.

Ductal carcinoma in situ (DCIS)

DCIS is confined to ductal cells.

No invasion of the underlying basement membrane occurs. Risk of axillary metastasis is <1%.

Treatment options

Excision with clear margins

Twenty-five percent risk of recurrence within 5 years

Recurrence may be invasive (50%) or DCIS (50%)

Excision with clear margins and radiation

Reduces risk of recurrence to 8%

Total (simple) mastectomy

Removal of breast tissue and areolar/nipple complex

No need to sample axillary nodes

Less than 1% chance of recurrence

Reconstruction can be done at the time of mastectomy.

Lobular carcinoma in situ (LCIS)

This type is most commonly found incidentally.

The risk of invasive cancer within 20 years is 15%–20% bilaterally.

Treatment involves careful follow-up, because the lesion is considered to be a marker for increased future risk of invasive cancer in both breasts. Bilateral total mastectomy may be considered if other risk factors are present (i.e., family history, other hormone -sensitive tumor, prior breast cancer).

Paget's disease

This uncommon lesion involves the nipple.

Histologically vacuolated cells (Paget's cells) are seen in the epidermis of the nipple and result in an eczematous dermatitis of the nipple.

Tubular carcinoma (grade 1 intraductal)

Colloid or mucinous carcinoma

Papillary carcinoma

Less favorable lesions

Medullary cancer. This type involves lymphocytic infiltration and a well-circumscribed lesion.

Invasive lobular cancer. Small cells infiltrate around benign ducts.

The prognosis is slightly better than for invasive ductal cancer.

There is a higher incidence of bilaterality.

Least favorable histologic type

Inflammatory breast cancer. The histology involves tumor-plugged subdermal lymphatics. The prognosis is a 5-year survival rate in approximately 30% of patients. Inflammatory signs are seen (e.g., warmth, swelling and pain).

F Staging and prognosis of breast cancer

After the diagnosis of breast cancer is made, the next step is to determine the extent of disease. This process of staging guides treatment and also predicts survival.

Clinical staging. Based on physical exam and mammogram. Distant disease is evaluated with chest x-ray, bone scan, liver function tests (LFT).

A mammogram is useful to determine both additional foci in the involved breast and the presence of metastatic or synchronous disease.

A chest radiograph detects pulmonary parenchymal or bone metastasis.

A computed tomography (CT) scan of the chest should be obtained for stage III patients to evaluate the supraclavicular area and mediastinum or if the chest radiograph is abnormal.

LFTs

Alkaline phosphatase is the most sensitive in detecting hepatic metastasis.

TABLE 23-3 Breast Cancer Prognosis Based on Stage

An ultrasound or a CT scan of the liver should be performed if the alkaline phosphatase level is abnormal or if other evidence of distant metastasis is present.

A bone scan should be performed if nodes are clinically positive or if nodes are clinically negative but the patient has symptoms of bone pain (patients in stages II, III, and IV).

A CT scan of the head should be done if neurologic signs or symptoms are present.

Clinical/pathologic staging

Tumor (T)

Tis = carcinoma in situ

T1 = Tumor 2 cm or less in greatest dimension

T2 = Tumor greater than 2 cm but no more than 5 cm

T3 = Tumor greater than 5 cm in greatest dimension

T4 = Tumor of any size with direct extension to chest wall (not pectoralis major) or skin

(1) Poor prognostic features include:

Edema or ulceration of the surrounding skin.

Tumor fixed to the chest wall or overlying skin.

Satellite skin nodules

Dermal lymphatic invasion. Peau d'orange is an orange -peel consistency of breast skin. Skin retraction and dimpling (shortening of tumor-involved Cooper's ligaments) occur.

Axillary node status (N) remains the best source of predicting survival or outcome.

N0 = No axillary metastasis

N1 = Metastases to movable axillary nodes

N2 = Metastases to fixed, matted axillary nodes

N3 = Metastases to ipsilateral internal mammary nodes

(1) Poor prognostic features include:

Capsular invasion

Extranodal spread

Edema of the arm

Distant disease/metastasis (M)

M0 = No distant metastases

M1 = Distant metastases, including ipsilateral supraclavicular nodes

(1) Sites of metastasis

Lung

Liver

Bone

Brain

Adrenal

G Treatment of breast cancer

Multimodality therapy that can include surgery, chemotherapy, radiation and/or hormonal therapy

Surgery

Most women are candidates for breast conservation or mastectomy. Much of the decision making, when medically appropriate, involves patient preference.

Breast Conservation. There is no survival difference between breast conservation (with or without radiation) and mastectomy. There is an increase in recurrence with breast conservation.

Lumpectomy with negative margins

Lumpectomy alone: 25% rate of recurrence

Lumpectomy with radiation: 8% rate of recurrence

Must include axillary sampling to accurately stage patient

Axillary lymphadenectomy (Fig. 23 -1)

Level I and II nodes are removed in relation to the axillary vein (Fig. 23 -2).

Skip metastasis (i.e., involved level III nodes with negative level I and II nodes) occurs in fewer than 5% of cases.

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FIGURE 23-2 The lymphatic drainage of the breast, showing lymph node groups and levels. Level I lymph nodes, lateral to lateral border of the pectoralis minor muscle; level II lymph nodes, behind the pectoralis minor muscle; level III lymph nodes, the medial to medial border of the pectoralis minor muscle.

Sentinel node biopsy

This biopsy allows minimal dissection with a substantial decrease in morbidity (lymphedema).

Nuclear scanning or vital blue dye is used to identify the first node drained by the breast.

This node is then examined for the presence of axillary disease. If the sentinel node is negative for metastatic disease, no further lymphadenectomy is performed. If the sentinel node is positive for metastatic disease, a standard lymphadenectomy is performed to stage the axilla.

The long thoracic nerve should be carefully preserved to prevent denervation of the serratus anterior muscle, which results in a winged scapula. The thoracodorsal nerve and blood supply to the latissimus muscle are also preserved.

Patients who choose breast conservation therapy should also undergo radiation therapy to decrease the risk of recurrence. Breast conservation cannot be performed for patients who have undergone chest radiation, have diffuse multicentric disease, collagen vascular disease, or persistent positive margins after lumpectomy. These patients are more effectively treated by mastectomy. Patients with a large tumor in relation to breast size may have superior cosmetic result with mastectomy.

Mastectomy is removal of the breast tissue and nipple/areolar complex.

Modified radical mastectomy includes axillary dissection/sentinel lymph node biopsy (Fig. 23 - 3).

Skin -sparing mastectomy (nonareolar breast skin is preserved) with immediate reconstruction

provides more cosmetic result and does not increase the risk of recurrence.

Radical mastectomy includes the pectoralis major muscle. It is used in the therapy of tumors invading that muscle.

Patients who are not candidates for surgery include those with:

Extensive edema of the breast

Satellite nodules of carcinoma

Inflammatory carcinoma

A parasternal tumor, indicating spread to the internal mammary nodes

Supraclavicular metastasis

Edema of the arm

Distant metastasis

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FIGURE 23-3 The borders of a mastectomy. Superior, clavicle; lateral, lateral border of the pectoralis major muscle; inferior, the inframammary fold (fifth to sixth rib); medial, the sternum.

Radiation

Whole breast radiation involves 4,500 rads. A boost of 2,000 rads is given to the tumor site.

Radiation therapy can be useful as adjuvant therapy after mastectomy in high-risk patients or in those with chest wall involvement.

Chemotherapy

Candidates for chemotherapy include node-positive patients, patients with tumor >1 cm, and estrogen receptor/progresterone receptor (ER/PR)-negative patients

Common chemotherapy drugs include cyclophosphamide (C), methotrexate (M), fluorouracil (F), and adriamycin (A)

Different combination drug regimens, given together for 3 to 6 months, include CMF, CAF, AC, and AC followed by paclitaxel (Taxol).

The results show improvement in both the diseasefree interval and the overall survival of premenopausal women.

Side effects

Myelosuppression requires monitoring of bone marrow function.

Alopecia

Cardiomyopathy (with adriamycin only)

Chemotherapy and hormone therapy are also used to treat recurrent and metastatic disease.

Neoadjuvant therapy is chemotherapy given before surgical therapy of local disease.

Inflammatory breast cancer. Diffuse intraductal invasive breast cancer requires chemotherapy treatment immediately.

Large fixed tumors or fixed nodal disease

Can downstage disease and enable resectability

Can also decrease tumor size and allow breast conservation

Can increase overall survival

Hormonal therapy –for ER/PR-positive patients. ER/PR-positive patients in general have better prognosis.

Tamoxifen or raloxifene (antiestrogens) or anastrozole (Arimidex) (aromatase inhibitor) are taken for 5 years.

Hormonal therapy is as effective as chemotherapy in postmenopausal patients.

P.438

This therapy is an excellent choice of treatment in elderly persons who cannot tolerate chemotherapy. Adding tamoxifen decreases recurrence rates by 47% and death rates by 20%.

Side effects can include vaginal bleeding, hot flashes, thromboembolic events, and increased risk of endometrial cancer.

H Follow-up

(ipsilateral and contralateral breast)

Observation is made for tumor recurrence and complications.

Monthly SBE

Annual breast examination by a physician

Annual mammogram

Chest radiographs, CT scans, and tumor markers are not needed unless clinical suspicion arises.

Edema of the arm

Ten percent of women who have had axillary lymphadenectomy or modified radical mastectomy develop edema of the arm (acute or chronic).

Edema is worsened by radiation therapy to the axilla.

All minor trauma to the affected arm must be avoided.

Treatment

Because each infection increases lymphatic obstruction by obliterating the remaining open channels with fibrosis in reaction to the bacteria, even minor skin infections should receive early treatment with antibiotics.

Chronic edema can be treated with an elastic sleeve or a pneumatic compression device.

Complications. Chronic edema lasting 10 years or longer can lead (although rarely) to the development of lymphangiosarcoma in the affected arm.

I Recurrent disease

Patients with a recurrence in the first 2 years after treatment have a worse prognosis than do patients who have a recurrence after 5 years.

Most recurrences occur in the same quadrant as the original lesion.

Metastatic disease is present in 10% of patients with recurrence.

The treatment of an isolated breast recurrence after primary radiation therapy is mastectomy.

Radiation therapy can be a very effective form of palliative therapy in patients with bone or central nervous system metastases, resulting in relief of pain and control of local disease.

A local or regional recurrence can involve the operative field of a mastectomy, the breast after primary radiation therapy, or the axilla. Larger tumor size, receptor -negative status, and involved axillary nodes are all risk factors for the development of local or regional recurrences.

Chest wall recurrences